Coping with antidepressant side effects

Not everyone has side effects but side effects of antidepressants can cause problems particularly when people start taking a new one. It can take several weeks before any benefits become noticeable. The doctor should give advice about what to expect when he or she prescribes a new antidepressant, and review progress regularly. There is written information about each medicine in the packet, which lists possible side effects and pharmacists are also able to provide advice. If side effects persist or are unbearable the GP may suggest trying another antidepressant which may suit someone better.

Research shows that like Simon (below), people often stop taking antidepressants in the first month after starting one, particularly if they experience side effects. Sonia had panic attacks soon after starting on Seroxat (paroxetine), and discontinued after a short while ‘I hadn’t had panic attacks before I started taking it... I didn’t like the way it made me feel. So I didn’t actually stay on it for very long’. Starting on half a dose for the first two weeks may help to reduce this type of side effect and the benefits of treatment should outweigh any problems after a few weeks. If they don’t people are advised to go back to see their GP.

Simon is married and has two young children. He is a GP who specialises in mental health issues, and also works as an academic and clinical teacher/researcher. Ethnic background: White British.

Yes the first time I was prescribed citalopram.

So when you first started taking it can you remember that first time how it made you feel?

I remember having a lot of side effects feeling very sick some diarrhoea some clenching of the jaw, tightness in my face it was quite unpleasant. I remember, you know, being in between lectures and feeling quite uncomfortable at home as well so I had a lot of side effects there. I don’t think the first time I was prescribed them I didn’t really take them long enough for the side effects to settle.

How long a period was that first time?

I reckon I took them for about three weeks regularly, I may have had prescriptions after that but I didn’t, I didn’t take them regularly.

So if you weren’t taking them regularly then do you know what the effect of that was on you, were you feeling different on days when you didn’t take it?

I’m trying to recall if the first time I took it I really took it, the first time I don’t think I took it regularly enough for it to really get into my system.

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Age at interview:

31

Sex:

Male

Background:

Simon is married and has two young children. He is a GP who specialises in mental health issues, and also works as an academic and clinical teacher/researcher. Ethnic background: White British.

Certainly, some especially the ones that are pretty much inevitable so it’s pretty much inevitable that people will feel sick when they first take it especially if they take it on an empty stomach, it’s pretty much inevitable they they’ll have some degree of change in bowel habit, some diarrhoea and often feel anxious just when they first take them and the amount of people who stop taking it within a month is huge. And I think the best way of minimising that is warning people it will make you feel rubbish for at least about two weeks possibly up to a month, it will get better is something that I always tell people. I always say look if you have any side effects think to yourself is this something you can put up with for a few weeks, if it is put up with it because it will get better. If it’s something that you feel you can’t put up with come back to me and we’ll change it, so I always warn people about those.

People want to know what to expect before they started taking an antidepressant. With the benefit of hindsight some of the people we interviewed said they hadn’t realised when they first started an antidepressant that you could try different types if side effects were too difficult to cope with or unsettling. People felt reassured when their doctor had provided information and talked to them to prepare them, especially about the possibility of initial side effects. Some wondered whether doctors were reluctant to give their patients too much information about side effects to avoid alarming them. If people do not realise or anticipate that it can take a while to adjust to an antidepressant they may not recognise new symptoms as side effects of their medicine. The instructions may advise that the medicine is taken with or after food, or at a certain time of day, to prevent some side effects, or minimise their impact.

Andrew is married and has two young children. He works in communications at a university undertaking health research.

The first six weeks was an odd experience, well no the first month, was quite an odd experience and I think my wife was a bit concerned about me.

In what way was it an odd experience?

I really felt like it was me, you know, like I was acting someone else’s life, it was like watching somebody else. And so I could sit completely still for half an hour and not even, not even know that I’d done it, you know?

So would it, is it like a sort of bit spaced out?

Yes it’s just like being spaced out yes. Well I’ve never really done drugs but it’s like being- just what you’d imagine it to be, just like you’re somebody else, your movements feel a bit odd I thought, because everyone’s different I’m sure you know it affects people quite differently I could be at work, we can talk about work in a minute if you like.

Yes.

But I could be at work and I could sit in front of the computer… and I’d be thinking… nothing really, you know, it just come to a halt almost. And a kind of warm feeling in my head and I mean they were the main sort of, I didn’t have any sleep problems, some people report difficulty sleeping I never had even with the depression I never really had sleep problems, I could sleep, probably found I was sleeping a lot well certainly sleeping a lot more with the depression, or nodding off falling asleep, feeling very tired. But with these things they didn’t seem to affect me, just a kind of slowness and you know that kicking in quite a lot. But I don’t get that now, I don’t really remember when it finished but I know after, certainly by about Christmas I was definitely feeling there was a massive change in, already then, in the way that I was dealing with the family, how calm I was.

Actually I’ve looked at some since, I looked at some forums on line where people have thinking about going on treatment or have just started. And I didn’t want to feel any worse and it did make me feel this in this odd place but it didn’t last long and I just thought I’ve got to do this, you know, I’ve got to. And the doctor had kind of underlined this to me that, he said you may not you may just find that you’re fine but he had said that it may make you feel a little bit odd at first. So I was primed and now all these months on I just think thank goodness I carried on, you know, and I really glad I persevered with it really, you know, I wouldn’t want to be in that place now.

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Age at interview:

31

Sex:

Male

Age at diagnosis:

30

Background:

Steve has done a lot of work in the field of hospitality and currently works for a charity. He lives with his boyfriend. Ethnic background: White British

I didn’t really take notice of how I was meant to take them so I what I was doing I was waking up in the morning and taking one because it’s 20 milligrams that I take taking one and then eating about lunch time so for quite a while I was feeling really sick and I didn’t really understand why. I’m not clever enough at all to have worked out that my sickness was probably to do with the fact that I’d been taking antidepressants and that’s what was new, I just kind of was going through day by day going ‘Why does my stomach feel like this, it’s never like this,’ because I’m quite fit and healthy in general but it was actually my step mum that turned around to me and she said ‘Well when, haven’t you just started taking a new drug?’ I said ‘oh yes.’ So it wasn’t like forgetting about it I just hadn’t like, I hadn’t associated the side effects with what I was doing. Then when I told her the way I was taking it she said well ‘Did the doctor not tell you that you should take them when you’ve had something to eat?’ and I was like ‘Yes they did.’ So then I just realised that it was probably just the way I was taking them and I’ve not really had that many side effects since then.

The patient information leaflet that comes in the packet provides details of potential side effects but some found it alarming to read because it covers such a wide range of possibilities. Commonly people used the internet or other sources of information to find out more, especially about others’ experiences, either before they started taking the medication, or if they were experiencing noticeable side effects. It can help to know how others’ have reacted, while being aware that people respond differently. (See ‘The Patient Information leaflet’, ‘Antidepressants: finding information’ and ‘Expectations about taking antidepressants’).

Rachel lives with her partner and is currently unable to work because of depression, but she worked as a support worker until fairly recently. She has three adult children. Ethnic background: White British.

I do ask as well because of the frightening leaflet, you know, I’ve had it where I’ve come home with something and then you read, you read the leaflet and then I haven’t taken them because it sounds so scary.

Right, what kind of things would it say that would scare you?

Well it seems to repeat the symptoms of what you’re suffering from already.......’you may feel suicidal’ or you think oh my God, you know.

It’s meant to stop me from feeling.....that?

Yes and I mean I again it’s something I try not do because, but I’m not always strong willed and I because I it’s almost like I, I sometimes think I kind of use it because then I can justify my lack of interest in taking it, ‘wow look at all these contraindications’

Can’t take that.

Yes so but pretend you know I’m quite good at, you know, stocking up my reasons why I can’t do.

Some people had no noticeable side effects. Others had tried different antidepressants and had different reactions to each, and some had quite different experiences of the same antidepressant when they had taken it at more than one time in their lives. Where people described side effects the intensity or impact varied widely and so did the degree of importance they placed on them. For some, side effects wore off after a short while, whilst others said they never went away. Clearly, side effects are more tolerable if there are also improvements in overall wellbeing. Often decisions about whether to continue taking an antidepressant are made by weighing up the benefits of taking medication against the side effects that people experience. Thomas said he made a list of ‘the pros and cons’. Rachel balanced her dislike of feeling numb against the fact that at times her mood was more level.

Lucy is a university student and works part time during the vacations as an administrator. Ethnic background: White British.

It was Prozac that I was taking at that point.

My experience of that wasn’t generally very good in the first two weeks I was very ill, I was like - lots of sickness and like headaches just feeling very dizzy and I really, I struggled to even get into school because I was feeling so terrible. And then once that settled down even after that I, I never really got on with it I felt really like distant from my emotions and like everything was a bit numbed and I really hated it. And I would sort of go and like protest that I wanted to not take them anymore and they’d obviously say that I could do, I could do what I wanted to do but they advised I kept doing it, kept taking them. And I think I kept that up for about half a year when I just decided that I couldn’t, I just couldn’t do it anymore so I stopped taking them.

And then when I went to university in my first year just as I came to university one of my close relatives was critically ill and then passed away just after the first term. And it was so difficult because I was away from home, none of my family or any people and just trying to cope and for me it took a very long time just to sort of accept that I would need help again because I felt I’d worked really hard to get through it the first time and to say you know, I was desperately trying to use all my CBT techniques to try to keep on board with everything and then it got to the point where I just thought oh you know this is more than I can deal with.

So I went back to the doctors and there I, so they suggested that I had counselling and anti-depressants again and I explained to them my feelings about taking Prozac and like I didn’t really want to take them again and I was speaking to my doctor and she explained that Prozac... with anti-depressants there’s lots out there and it’s about finding the right one for you and maybe that was the wrong one and that she was surprised that I sort of hadn’t been offered to change. And that’s when she prescribed me citalopram. And then I currently am still taking citalopram and it’s a completely, a million miles away from my experience with Prozac, I didn’t have any sickness when I first started taking them and I had absolutely no problems. I don’t feel the numbness, I don’t really feel like I’m taking anti-depressants other than my mood is much better.

Physical side effects people said they had experienced included; sweating, sickness, nausea, dry mouth, a metallic taste , itchy eyes, sedative effects, insomnia, migraine, headache, sugar craving, weight gain, weight loss, loss of appetite, vivid dreams, restless legs, trembling, yawning, anxiety, hallucinations, panic attacks, lack of concentration and sexual dysfunction. Some people didn’t worry too much about them, or they found ways to tolerate or counteract them. When Lou first started taking sertraline she couldn’t stop yawning and had a ‘clenchy jaw’. She looked it up on some online forums and found that other people also had these types of symptoms. Lofepramine makes Janet constipated, but she has been prescribed a laxative, which helps. But others found certain side effects impossible to tolerate.

Thomas is currently single and works as a researcher at a university.
Ethnic background: British Bangladeshi.

She prescribed me Cipramil which was dispensed by my GP, but it was prescribed under the direction of my, of my consultant psychiatrist at the time. And I started that on 20mg which is the starting dose for Cipramil. I found it again a very troublesome medication. So I would find that I would sweat profusely. So I’d go in a shirt and trousers, as I’m always dressed into meetings, and I would find that my shirt would be drenched within minutes. I would just sweat, sweat, sweat, sweat, sweat, that was very embarrassing. I’d have to carry around spare clothes with me to change because my shirt would be sodden with sweat.

I also - what really, really did it for me, was the sexual dysfunction. I got quite a lot of sexual dysfunction with citalopram. I found that very difficult to deal with, and I also got a feeling that I was just about to be sick. It was like eating, I don’t know, something like a double cheeseburger and it fills your stomach, and it should be so good, and then you feel permanently as if you’re about to be sick, but you never quite are. I suppose nauseous feelings. And I got a horrible metallic taste in my mouth. And nothing could quench that taste, apart from sugary drinks. So I would drink lots and of lots of coke. Anything with lots and lots of sugar in it. That would be the only thing that would cover the kind of metallic taste. It would always, always make me feel thirsty.

They tried various dosages to try to raise enough dosage up and I would keep chopping and changing the doses myself. Because I wondered if I could, if I changed the dose the side effects might be a bit different, but then they never seemed to be.

And the side effects were so immediately obvious, as I said, you know, sweating, sweating, sweating, sweating. My back was absolutely wet. I couldn’t actually hide it, so it was really quite a problematic medication for me. I have heard other people who were on it who did rather well, and did rather well on amitriptyline. I described it as kind of ‘devil’s poison’ or something. I absolutely hated it. I completely couldn’t believe that anyone would get any benefit from these things.

But the Cipramil gave me immediate side effects which were quite obvious which caused me practical problems, and were never explained, these side effects were never explained to me by GP. When I actually said, look I’m having sexual dysfunction problems with taking Cipramil, my GP actually said, “Oh I’ve never heard of those before.”

Even though it was on the patient information leaflet, wrapper that comes with the medication.

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Age at interview:

39

Sex:

Female

Age at diagnosis:

22

Background:

Lou is married and lives with her husband and young baby. She works as a manager in the public sector. Ethnic background: White/Asian

Seroxat?

Yes.

What were the side effects that you were feeling? Because you said that it made you feel quite numb and not there.

Well that was once the side effects had gone I felt more anxious by, you know, really anxious, really also, you know, initially the doctors said to keep taking it, you know the side effects will all work their way out in about six weeks and that was true.

So had you been warned initially to expect possibly some side effects?

Possibly some side effects but I mean I’d gone from feeling sort of depressed to kind of really, you know, having taken them I went from feeling, you know, depressed and anxious, anxiety was the biggest problem to feeling I wouldn’t say suicidal but getting there really not coping at all self-harming .

Can I ask what sort of thing you were doing?

Cutting my arms.

So had you ever done that before?

I don’t know because it was quite a long time ago, I don’t think so I certainly, it just everything I was feeling was amplified initially during the period when I first started talking those particular tablets until it then tailed off then it turns off, the side effects turn off to just feeling numb. And also really, really dry mouth, horrible taste in my mouth and insomnia couldn’t sleep, you know, racing thoughts. The anxiety was significantly worse.

And when you were going through that did you go back and speak to the GP about it, do you remember?

No I don’t think I did actually, you know, I remember I didn’t because I think I knew ‘oh they’re side effects and it will sort itself out.’

One side effect that people can find difficult to cope with or accept is ‘sexual dysfunction’. Some people told us that antidepressants had affected their relationships and sex lives. Symptoms such as loss of libido, or inability to climax can impact on close relationships, and can be difficult to balance against feeling well overall. Sharon said that most antidepressants she had tried had ‘shut off’ her sexual feelings which had caused difficulties in her relationships with her husband, but that for her, feeling well was more important. Thomas found this side effect difficult to accept ‘It’s part of me, you know, as a man and so on... it impacts on your self-esteem’.

Stuart is married and works part time as a teacher. He is also involved in voluntary activities to promote positive information about mental health. Ethnic Background: White British

So she referred me to a psychiatrist at the local hospital. And he said well obviously, you know, you’ve tried all the normal drugs why don’t we put you on venlafaxine which is it does the same as Prozac but inhibits or enhances one of the other neurotransmitters as well.

And that worked, I did see again quite a significant lift in mood after that but that one completely suppressed my libido, my sex drive, I had no interest - which was fine because I was single at the time. That, whether it was the drug whether it wasn’t… but I had quite a period then of being, you know, pretty stable in terms of mood but then a few years later I met my current wife and having no sex drive isn’t a very good approach to a new marriage. So I had to go back to back to citalopram which is what I’m on now, another SSRI.

It is a known, a possible side effect with a lot of the drugs and I still have a little bit of that from the drug I’m on, I think, I don’t know.

But it’s difficult because I know some people have said you read these, the you know the thing that comes in the pack.

Yes.

And it says ‘sexual dysfunction’, that’s the term that they use and there’s no more explanation than that.

No that’s true actually that could well do with more explanation of what people really experience. It’s not really; it’s not, well for me it’s not sexual dysfunction its sexual disinterest which is a different thing yes, yes.

Is that something you’ve ever been able to talk to other men or people about or is that something, because you said you were quite open about some of the things to do with your depression?

Yes well I’ve certainly talked and yes one or two but yes it’s not the sort of thing that you, it’s not the easiest of things, side effects to talk about, you can talk quite easily about the fact it's giving you a headache or making you feel sick or whatever.

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Age at interview:

37

Sex:

Female

Age at diagnosis:

22

Background:

Sharon is divorced and lives her two children. She works as a Lab Technician in a university. Ethnic background; White British.

With the majority of them I just wasn't interested at all, not in the least, didn't bother me one bit. With the fluoxetine and some of the other SSRIs it's like everything's plugged in properly but it's not switched on.

Good way to describe it....

So it's, yeah you can have urges and feelings but they weren't culminating anything no matter how hard you try which can be frustrating and then you think, 'Oh I can't, what's the point?'

And quite upsetting I imagine or not? Perhaps you weren’t feeling enough to be upset?

I wasn't too upset because I knew that was a side effect, well I'd read sexual dysfunction and then discovered what that was I suppose but I think for my husband it was probably quite frustrating and I did spend time explaining to him that it wasn't him, it was the medication you know, it's part and parcel of having that and the higher the dosage the worse it, the worse it got.

Was that ever something that you discussed with your doctor?

No, no.

Would there be a reason? Because it's difficult?

Because I think because it was more important to, to be well.

It’s important to speak to the doctor or pharmacist about side effects if they occur, so that they can be more easily managed. Some people felt their doctor had not offered enough support other than telling them to ‘stick with it’. Pharmacists can offer helpful advice about managing medicines.Thomas felt it would have been helpful to have advice about managing the side effects he was experiencing, rather than be told to persevere and hope they went away. ‘I wanted some way of treating the horrible taste I had in my mouth or some way of dealing with the feeling of always kind of wanting to be sick or just sweating’. Adjusting the dose, or changing the medicine might help, but Sonia said that each time her medicine was changed she had to adjust to new side effects, which could be difficult.

Thomas is currently single and works as a researcher at a university.
Ethnic background: British Bangladeshi.

It was treated fairly unsympathetically, they never had any, they never seemed to have any answers and so that’s one of the reasons why I kept looking in books and I kept trying, looking up papers, and what’s… I thought there’s got to be an answer. Someone’s got to have a treatment for this, for sexual dysfunction. Or the burning thirst, the metallic thirst, like it seemed that only sugar would ever quench. Someone’s got to have had an answer for this and I couldn’t find it in any of the books that I, that I read at the time. No one had a side effects solution. That’s what I was looking for - side effect. How to treat it. Sexual dysfunction. Burning taste in your mouth. Nauseous. Feeling as if you’re going to be sick.

Those are quite powerful things to have to cope with, especially if the actual drug isn’t doing what you’re hoping it’s going to do. Which sounds like it wasn’t really.

Well the people that I was seeing at the time, my GP and my consultant were saying give it time, give it time, you know, it’ll kick in. And I, I was saying to them, “Look, it’s not doing any good.

It sort of eroded my confidence really, that they really knew what they were doing, or did these medications work, and all these side effects that I got from these medications also made me lose confidence, because they couldn’t tell me it seems how to manage them. They’re…well the only suggestion I got the first was I think it was have a Polo mint, you know, and I was, I was very dismissive about this, I thought come on you, you must have something better, there must be a spray or something, or you know, give me something. And the sexual dysfunction as well which I got absolutely no answer for. You know, what’s going on? And that made me just lose confidence in them, everything.

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Age at interview:

31

Sex:

Female

Age at diagnosis:

17

Background:

Sonia is single and works as an administrator for a healthcare provider. Ethnic Background: British/Indian

That’s another thing that is really difficult is that, you know, certainly for me in the last three, since June so the last three months, my medication’s been changed three times and you have to just kind of sit out the side effects and wait for them to calm down. You can’t go back to your consultant and say, you know, after two days ‘Oh do you know what this isn’t working,’ even kind of when I, when she added mirtazapine in June, I was suicidal when she prescribed it, I felt it got worse in the week immediately after I started taking the mirtazapine and I spoke to the mental health team and said I don’t know if it’s a coincidence but I don’t think it is because my moods have deteriorated so rapidly and they kind of insist that you stick with it and you don’t really know which to do because you’re kind of thinking well you know what you’re talking about, you are the experts, you are the doctors but equally you’re thinking, I know what I’m feeling.

I’m fairly confident I will be on medication for… a very long time if not the rest of my life. I don’t like it, I don’t really accept it, I kind of half do and half don’t, I am scared that I will have to keep changing because, you know 13 years on God knows how many different medications, I’m scared that’s going to keep happening.

Sometimes a side effect of an antidepressant can be positive, for example sleep problems are common with depression. People with insomnia can find the sedative side effects of some antidepressants help them to establish a sleep routine and sometimes a particular antidepressant will be prescribed for this purpose. Others found that their antidepressants had left them feeling so sedated they couldn’t function at all. Changing the time of day that the medication is taken can help with this, or the doctor may alter the dose or change to different antidepressant if the problems persist.

Olivia Y is single and currently lives alone. She is studying for a PhD. Ethnic background: White British

I’d taken 10 milligrams of citalopram that time before and I hadn’t felt any side effects, the citalopram this time around… I was taking 20 milligrams every morning as instructed and I just wasn’t sleeping, I can’t remember if it was trouble getting to sleep or if it was waking up early, I can’t remember which but my sleep cycle was messed up. So without asking my doctor I switched to taking it at bedtime, that fixed it, just simply moving it from morning to night, I don’t know how these things work, I’m not a, I’m not well I’m not a medic, I’m not into kind of stuff but I don’t know when I moved it to 12 hours later I slept better. it took about six weeks I have to say for that to get into my system that was not an easy experience getting it into my system, I don’t know maybe if it would have levelled it anyway maybe if I’d continued taking it in the morning maybe that would have just have, maybe it was just levelling out anyway or I don’t know if making the switch was what levelled it.

I remember I was on the internet Googling’ how long does citalopram take?’ and like everyone had written yes it takes six weeks to eight weeks and I remember thinking okay that’s four weeks, two more weeks, that’s five weeks like I was consulting these online forums.

And was that looking to find out how, when it was going to start making you feel better or to get your sleep back into sync?

When the, with the kicking in, basically when the getting it into my system was going to finish. it definitely took a while but apparently this is common with citalopram it’s a tough one to get used to and I hadn’t noticed it with the 10 milligrams but oh yeah, with the 20 definitely.

People with depression may often also have problems or issues around eating; some of the people we spoke to believed that taking an antidepressant had affected their appetite. Sonia craved sugar when she took mirtazapine and gained weight, which she said was not helpful given that she had an eating disorder since she was 17. Lofepramine curbed her appetite, which she liked because it helped her to maintain her weight, but looking back felt it was not sensible to give someone with an eating disorder a drug that could stop them wanting to eat. ‘I had absolutely no desire to eat at all and, you know, I wanted to lose weight I wanted to not eat’. Catherine said she had gained a lot of weight on mirtazapine and that it had affected her self- esteem. Flora lost weight and had no appetite when she took citalopram, and said she lost the motivation or inclination to cook or shop for the family.

Dina is single and works as a researcher in mental health. Ethnic background: White European/Greek

I guess you know the weight gain again is one of the, like the mirtazapine I think out of all the antidepressants that I’ve taken it’s probably the one that has, you know, caused the most weight gain, you know. And again of course the weight gain is not just about drugs, the tablets it’s because like for example in hospital the only thing that I had any control on was food so, you know, I was eating nine bars of Twix at once which is like… my God, you know how can anyone do that. I mean before, before my episode I was 55 kilos which has doubled and of course that’s not just about the tablets it's also about, you know, using food as... well… comfort, sometimes comfort and sometimes a way to harm myself.

People also described psychological side effects such as feeling numb, distant, detached or inability to concentrate. The degree to which people found this acceptable or tolerable varied. People described feeling ‘detached from reality’, ‘not myself’ and ‘zombie like’. Sharon felt ‘floaty’ as if she was ‘in a permanent state of drunkenness’ when she took mirtazapine, and that although it was a relief not to feel anything for a while, ‘you can’t go on like that, it’s not how you live’. Some said they had felt worse rather than better for example because the antidepressant had seemed to heighten or accentuate feelings of anxiety, paranoia, or suicidal thoughts. These types of effects may or may not lessen over time. Rachel said antidepressants helped her to some extent in that they kept her from feeling hopeless, but when she was taking them she always felt numb and distant ‘they shave off so much of the motivation and... creativity, they limit how much joy you can experience in your life’. It can be very difficult to know how much these types of feelings are a symptom of the depression itself, or a side effect from the medication.’

The GP should review how you are feeling a few weeks after you first start on an antidepressant, or earlier if the side effects are distressing. You can also discuss these issues with the pharmacist who may be able to suggest simple ways to alleviate side effects such as changing the time of day you take them, changing the dose, or suggesting you try a different antidepressant. Sometimes people decide to stop taking them without seeing the GP. Stopping suddenly can induce symptoms (discontinuation symptoms) which may be similar to unwanted side effects so it is recommended to come off them slowly, and to get advice.